GAO Findings. Federal law requires state survey agencies to investigate allegations of resident abuse and neglect stemming from complaints and facility-reported incidents. About three-quarters of all abuse violations nationwide stem from these investigations. Unfortunately, a recently published management report by the U.S. Government Accountability Office (GAO) concludes that the Centers for Medicare & Medicaid Services (CMS) failed to oversee the nursing home inspection process in Oregon to ensure compliance with this requirement. According to the GAO, Oregon’s Adult Protective Services (APS), not the state survey agency, has been investigating complaints and facility-reported cases of abuse in the state for at least fifteen years. The GAO’s report notes that, unlike state surveyors, APS investigators “are not trained in, or focused on, investigating abuse according to the federal nursing home regulations.”

CMS Response. CMS claims that it became aware of this astounding failure in oversight in July 2016, but the GAO notes that evidence suggests CMS previously became aware of Oregon’s improper practice in the early 2000s. Oregon’s Department of Human Services communicated to the GAO that CMS had known about the practice for “many years and said state policy changes made in 2002 regarding nursing home abuse complaints and facility-reported incidents were made at the direction of CMS.” CMS has expressed that, while there is no indication that other states are out-of-compliance with the federal requirements, “their current approach for overseeing survey agencies does not specifically examine whether survey agencies are taking responsibility for investigating all nursing home complaints and facility-reported incidents.”

Fundamentally, the GAO’s findings provide further substantiation that CMS and the state agencies too often fail to protect residents or hold providers accountable for abuse and neglect.

Report’s Implications. CMS’s failure means that the federal agency has not be able to properly penalize deficient nursing homes for complaint and facility-reported cases of resident abuse for fifteen years. Additionally, the failure means that Medicare’s Nursing Home Compare website does not provide the public with an accurate accounting of nursing home quality in Oregon. For example, as the GAO report notes, a 2015 substantiated allegation of sexual abuse by a staff member is not on Nursing Home Compare. Similarly, 2016 APS investigations of resident-to-resident abuse were not reported to CMS, making CMS unable to identify the nursing home’s failure “to prevent, investigate, or report abuse, nor could federal nursing home deficiency penalties be imposed.”

Key Recommendation. Among several recommendations, the GAO called on CMS to evaluate the nursing home inspection process of all states to ensure state survey agencies are meeting federal requirements.

Concerns for Residents and Families. Our organizations are extremely concerned by the GAO’s findings and their implications for basic resident safety and accountability. As the report indicates, CMS’s failure to properly oversee the nursing home inspection process may extend to other states throughout the country. Until CMS completes its nationwide evaluation of nursing home inspection processes, which it has agreed to do, there is no way of adequately determining whether countless other cases of resident harm have been left unaccounted for by the federal government and for how long. Fundamentally, the GAO’s findings provide further substantiation that CMS and the state agencies too often fail to protect residents or hold providers accountable for abuse and neglect. Our organizations call on Congress to hold a hearing into CMS’s failure to properly oversee the nursing home inspection process in Oregon and potentially other states.